Provider Demographics
NPI:1649430554
Name:MIKS, MIZUE (LMT)
Entity type:Individual
Prefix:MRS
First Name:MIZUE
Middle Name:
Last Name:MIKS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 HANGING ROCK PL
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80108-7452
Mailing Address - Country:US
Mailing Address - Phone:540-808-3479
Mailing Address - Fax:
Practice Address - Street 1:422 ELBERT ST STE D
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-2411
Practice Address - Country:US
Practice Address - Phone:540-808-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-13
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47627225700000X
COMT0020612225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist